Basic Information
Provider Information | |||||||||
NPI: | 1902860406 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FERRELL | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: | REBECCA | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ALEXANDER | ||||||||
OtherFirstName: | JENNIFER | ||||||||
OtherMiddleName: | REBECCA | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | DO | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1323 W 6TH AVE | ||||||||
Address2: |   | ||||||||
City: | STILLWATER | ||||||||
State: | OK | ||||||||
PostalCode: | 740744306 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4053721480 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1323 W 6TH AVE | ||||||||
Address2: |   | ||||||||
City: | STILLWATER | ||||||||
State: | OK | ||||||||
PostalCode: | 740744306 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4053721480 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/13/2006 | ||||||||
LastUpdateDate: | 02/24/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | L7640 | TX | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | 4995 | OK | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 164990701 | 05 | TX |   | MEDICAID | 8P5795 | 01 | TX | BCBS | OTHER | 7471615 | 01 | TX | AETNA | OTHER | 164990702 | 05 | TX |   | MEDICAID |